March 29, 2023

How Do Healthcare Facilities Maintain Compliance with JCAHO?

jcaho compliance

What does JCAHO stand for? The Joint Commission on Accreditation of Healthcare Organizations, also known as the Joint Commission, which is to healthcare organizations what the six regional accrediting bodies of the Department of Education are to higher education. The Joint Commission oversees the accreditation of the nation’s healthcare facilities. The Joint Commission has had a history of 55 years as an effective organization. It operated from 1951 until 1965 as an advisory organization but had little or no impact on the healthcare industry. It was only after Medicare came into being that the U.S. government assigned it any real authority.

The Joint Commission on Accreditation of Healthcare Organizations is an independent, not-for-profit organization whose primary mission is to set standards and offer pathways to accreditation for healthcare organizations. The JCAHO, now known as The Joint Commission, advocates for the continuous improvement of the quality of care and standards of safety of healthcare practices by conducting surveys, identifying points for improvement and offering other platforms to support performance improvement of healthcare entities.

Understanding the Accreditation Survey

Pursuing accreditation and certification is voluntary on the part of healthcare organizations. The survey is conducted by a team of accredited professionals who are experts in their field, including hospital administrators, doctors, nurses, medical technologists, and other healthcare professions. Regular survey schedules are unannounced, but surveys are conducted every 39 months except for laboratories where surveys are conducted once every 24 months. Results of the onsite survey are typically available within two weeks to two months after the survey date. However, accreditation is a continuous process because health organizations are asked to submit performance data on a consistent basis. Self-assessment surveys support the process of monitoring and improving standards of care. The accreditation is good for a period of three years for all health care organizations except for laboratories that have to re-certify every two years.

The Joint Commission accredits hospitals, nursing care centers, home care providers, organizations that provide behavioral healthcare, and ambulatory care providers. Each of these has different standards of excellence and must achieve different criteria to earn accreditation. All of the criteria, despite their differences, are evidence-based and focus on the properties and characteristics of the organization to be accredited. Although the criteria are demanding, they are not unachievable nor unreasonable. As these accreditations are voluntary, that just makes sense.

The Joint Commission recommends that organizations go through mock accreditation surveys in the same ways as prospective job applicants do with mock interviews. The Joint Commission provides organizations with comprehensive lists of requirements and standards, and the staff of the organization then performs its own assessment of its readiness for accreditation. As a result, the staff can determine where it’s lacking and make the applicable changes to meet the standard before having the “real deal.” Most important, they can estimate how long it will take the organization to measure up so that they know when they can plan for the full accreditation survey.

Focus on Accreditation Standards

How Do Healthcare Facilities Maintain Compliance with JCAHO?

The main goal of the Joint Commission is to define, monitor and support improvements in the delivery of healthcare with emphases on patient safety and quality standards of care. Currently, the accreditation standards include 250 points, covering infection control, medication safety, and management, error prevention and reporting, staff credentialing and certification, emergency management, patient rights, privacy, and education. Health organizations have to specify how patient and performance data is generated and how they use the information to improve standards and practices.

When it comes to patient safety goals, there are eight categories where organizations must meet the standards. They include ambulatory care, behavioral care, critical access, home care, hospital care, lab services, nursing care, and office-based healthcare. The office-based category includes same-day, outpatient care.

As an example, the Critical Access Hospital National Patient Safety Goals comprise seven subcategories. Organizations must identify patients correctly by relying on multiple pieces of information, such as name, date of birth, birth address, and current address. The healthcare facility must know who is who so that they don’t make medication or treatment mistakes that could cause death.

They must also use medicines effectively and safely. Everything must be correctly labeled. Before procedures, staff should ensure that all dosages are right and that syringes are sterile. All doses must be recorded and patient histories tracked and updated. Most important of all, staff must ensure that there are no medicinal contraindications. By adhering to these standards, the facility will provide the right kind of care and fulfill its medicinal obligations.

To achieve accreditation, facilities must also improve their internal communications. The right medical professionals need the right test results and must match them to their patients, which is why patient identification is paramount. With proper internal communication, results are timely. That’s always crucial in providing great care for patients.

Secondary to the internal communication protocols, communication between patients and staff is no less important, particularly in reference to adhering to HIPAA guidelines. For example, nonverbal patients still must be properly identifiable. The same holds true for patients with developmental disabilities that preclude them from either communicating their information or understanding the responses during that conversation. It is not just the facilities’ policies that are important regarding this matter. Every staff member must be committed to patient privacy as well as identification.

Patients who speak different languages must have access to skilled and experienced translators so that they will understand their care and treatment plans. Nowhere is this more applicable than in the case of patients who speak “low-incidence languages.” Patients who are refugees from African or Central Asian countries, some of which have populations smaller than average American cities, may speak languages with only a few thousand speakers worldwide. If these patients do not speak English, too, then communicating with them would be a significant challenge.

Equipment must also be in top-flight condition. Alarms must sound the way they should. Critically ill patients might need “full measures” at any time, and a faulty alarm could be the difference between life and death. Preventing infection goes with proper equipment handling and preparation and correct medicinal procedures, and during a pandemic, these standards are of utmost importance.

Patient identification goes together with diligence in maintaining proper records so that surgical mistakes don’t happen. That includes giving a patient who needs surgery the wrong treatment and also performing surgery on someone who doesn’t need it. The natural progression of all of these criteria is patient safety, which also includes suicide prevention.

Each of the eight categories has a similar number of subsections, so achieving accreditation is a long process that requires dedication, attention to detail, and consummate professionalism. This outline is just the “simple version.” The full version of the processes for the Critical Access Hospital National Patient Safety Goals is 15 pages long.

Pursuing and Maintaining Accreditation

The accreditation report is the comprehensive report produced by the Joint Commission survey team. It will include a list of RFIs or requirements for improvement as well as supplemental data and observations, all of which are part of the report sent to the Joint Commission Central Office and later posted to the extranet site for public access.

The number of RFIs submitted by the survey team can determine full accreditation or conditional accreditation. Health care organizations can either take corrective action or appeal the findings of the survey team. Within 45 days of the survey, the health organization must submit an ESC, which stands for evidence of standards compliance. This is a point-by-point report that outlines in detail any corrective action undertaken by the organization to address the cited RFI. The ESC must be accompanied by an MOS, also known as measure of success, which is a report generated by interviewing staff, conducting an audit and facility inspections to determine the effectiveness of the corrective action. The MOS is quantifiable with the performance tiers defined as follows: non-compliance for a 79 percent and below MOS, partial compliance for an MOS between 80 to 89 percent and satisfactory compliance for an MOS 90 percent and higher.

Other Accreditations

Aside from the general guidelines for accreditation, there are also specific guidelines for specialties that some facilities will provide while others do not. The Joint Commission awards certificates for facilities that achieve one or more additional sets of guidelines. Those certificates include palliative care, advanced cardiac care, primary home medical care, and perinatal care among others.

The cardiac care certification breaks down into further subcategories. They are:

  • Clinical Care Classification System
  • Public Health Advisory Council Guidelines
  • Acute Heart Attack Ready
  • Advanced Certification Heart Failure

How Do Healthcare Facilities Maintain Compliance with JCAHO?

These subcategories contain requirements for member organizations. For example, to be rated under the Clinical Care Classification System, or CCC, an organization must have performed at least 125 coronary artery bypass graftings. Additionally, it must have done at least 50 valve replacements, 200 percutaneous coronary interventions, and 36 primary PCIs.

Patient identification is also essential on a purely practical level. Facilities must maintain patient privacy as part of their compliance with the Health Insurance Portability and Accountability Act. Under HIPAA guidelines, breaches of patient privacy can be punished by a fine of up to $50,000 and up to a year in prison.

The organization must also have extensive and adequate diagnostic testing facilities and a cardiac catheterization laboratory that is accessible all day every day. Fully trained and certified staff must be available 24/7 as well. As far as the education of staff is concerned, all are required to study a certain number of hours annually based upon their personal qualifications. The organization must also sponsor six or more community outreach programs about cardiac health.

According to the CCC system, the leader of the medical facility must be a physician. This is in contrast to a facility that operates under Public Health Advisory Council Guidelines. In this case, the leadership must consist of both a professional medical director and a coordinator familiar with ST-Elevation Myocardial Infarctions or STEMI. Having a STEMI person as part of the leadership is also a requirement of any facility that is designated Acute Heart Attack Ready.

For a facility or organization to be designated Advanced Certification Heart Failure, it must have a leadership staff that has extensive experience with heart failure patients. In ACHF facilities as well as facilities with the other classifications, patients must be able to receive an EKG with 12 leads within 10 minutes of arrival. ACHF facilities focus more on ongoing heart disease maintenance than facilities that don’t carry the designation. After acute treatment, these facilities provide patients and their families with long-term solutions. They discuss treatment options, general prognosis, and other considerations for the future.

When it comes to the PHAC classification, STEMI-qualified staff members must maintain their qualifications annually both by performing the associated procedures themselves or by working to refine and improve the procedures to improve patient outcomes.

In the same way as organizations that conform to ACHF guidelines, AHAR facilities and organizations participate in the “Get With the Guidelines® Coronary Artery Disease” program from the American Heart Association. They, too, focus on STEMI patients and have much the same requirements for staff training and continuing education as facilities that meet the criteria of these other cardiac programs.


How Do Healthcare Facilities Maintain Compliance with JCAHO?

What does JCAHO stand for? The organization stands for excellence in patient care at hospitals and other healthcare facilities in the United States. As can be seen, the accreditation process is both thorough and complex. Few facilities achieve accreditation in every discipline and category, but doing so is not necessary for accreditation in one or more of the categories the Joint Commission implements.

Through diligence and a desire to serve patients as safely and comprehensively as possible, healthcare facilities and other organizations can rely upon the stalwart professionalism, complete transparency, and desire to serve of the Joint Commission. Facilities managers and other leadership staff can gain further clarification and information from the Joint Commission‘s website, which covers almost any question such managers may have.

It is important for health care facilities to maintain compliance with JCAHO standards to assure stakeholders that they are operating effectively guided by the highest standards of care for the safety of patients and staff. Although a Joint Commission accreditation is voluntary, it is an indication of the organization’s commitment to delivering quality health care and pursuing best practices to ensure positive patient encounters and limit medical errors while supporting staff and public safety.

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